If any contents are found they are saved for examination. If these are food from the previous night they at once tell of imperfect digestion and delayed emptying of the stomach, and the cause of such delayed emptying must be sought for. If not food, but gastric secretion, its acidity and composition must be determined. In either case the contents are subjected to the full examination already ascribed to the test-meal. Mucus in excess is easily recognized. Normally it should not exceed onehalf teaspoonful.

If the stomach be empty, a test breakfast of two ounces of rice-cake and a glass of water is next given. This is removed in sixty minutes, and while the tube is still in place the stomach is distended with water. This test with the patient in the upright position gives an absolute test for the greater curvature, and for this purpose is much more reliable than distending the stomach with gas. With the tube still in place the water is siphoned out and the stomach is distended by means of the tartaric acid and sodium bicarbonate powders. The stomach thus distended can easily be mapped out in all its dimensions by means of percussion. We give the sixty grains of tartaric acid first in order to avoid retching due to the premature formation of gas in an already acid stomach, if the eighty grains of sodium bicarbonate were first given.

In these cases when we may not wish to use the tube, but where nevertheless we desire to distend the stomach by means of gas, we have found it perfectly safe, notwithstanding many writers to the contrary, to give the powders by mouth dissolved in a little water. By giving the soda last and in two or three divided doses, the amount of gas generated can be kept under control.

There should be no difficulty in differentiating with or without the stethoscope between the stomach and colon. If the colon be full of gas the demarcation will best be made out while the stomach is distended with water; if the colon be filled with feces, the stomach distended with gas will give the most striking picture. While the stomach is thus distended tumors or indurations of its walls or pylorus are sought for. In differentiating between neoplasms nearby, but not in the stomach, their movement with respiration is carefully noted. A stomach fully distended with gas will often throw an enlarged or dis

eased gall-bladder forward so that it can be clearly palpated and separated from a thickened pylorus.

In conclusion: It is desirable to ascertain as much as possible from one method of examination before proceeding to the next, and to make all possible use of the simpler methods before attempting the more elaborate.

DISCUSSION

Dr. J. W. Andrews: The writer spoke about getting a history of the case, and it occurred to me how difficult it often is to get a correct history in the case of the stomach, or otherwise. As to the physical examination: I have examined many stomachs, and I do not believe that there is much difference in the distensibility of a healthy stomach. I mean that if the stomach is distended below the umbilicus you can pretty surely lay it to a diseased stomach; and rarely have I found the curvature of the stomach extended below the umbilicus, but what there were symptoms that would lead one to believe there was an enormous dilatation. I have examined healthy stomachs and got a correct outline, and whether extended with gas, as the writer suggests, or with soda, acid, or with water, I have found that the distention does not extend below the umbilicus, but about two fingers' breadth above it; and where it does extend below, I found a diseased stomach that does not empty itself well, and where a patient vomited at all it was a great deal of sour matter. I noticed in the Journal of the American Medical Association a new and rather novel method of determining the outline of the stomach, namely, to fill the stomach full of water by means of a double tube, then blowing air through one tube the air rises through the water, and, the writer states, one can be very accurate in determining the outline of the stomach. If the stethoscope is placed a trifle below the stomach the sound is much less distinct, but if the stethoscope is placed over the stomach the sound is very distinct. Machinery of that kind is unnecessary. There are few patients, unless they have become accustomed to the stomach-tube, who would be willing to have made the test I have just spoken of. The stomach can be outlined very definitely by means of the stethoscope and percussion. I think with a little experience one can almost exactly outline the stomach with the stethoscope.

Dr. T. F. Quinby: It seems a little like presumption on my part to criticise the excellent paper that Dr. Rees has read. I agree with him on essentials. I cannot agree with the statement of the gentleman, if I understood him correctly, who thought that extension below the umbilicus is dilatation. It is well known that we have many cases of so-called gastroptosis in which the outline of the stomach may lie several inches below the umbilicus, yet the cubic contents or the capacity of the stomach be not increased. There is no decrease in its muscular extent and ability to expel its contents, provided there is no obstruction of the pyloric orifice. In mapping out the curvature, it is the general custom to first percuss very carefully the abdomen, marking in blue pencil where there is a change of note between

the colon distended, which will determine the lower curvature of the stomach; then the patient is given about a quart of water, and percussion is again made. If there is a shadow of doubt the quantity of water is increased to a liter or more. It is a fact that the normal stomach, regardless of the amount of water introduced, will not be changed. You may pour one liter or two into the stomach, and hold it without changing the relative position of its lower curvature. The presence of a liter of water in the stomach will give you a distinct outline, which should be about five-eighths of an inch above the umbilicus. Should any doubt exist a double balloon is attached, and air dilitation made through it. The patient is instructed to raise the hand at the first indication of discomfort. It is not necessary to use the stethoscope, but by simply placing the hand on the stomach the gurgle is distinctly felt. With the upper part of the stomach thoroughly distended you can make out a map with distinctness. But, as a rule, if the lower curvature is found in the proper position, you may be pretty sure the upper curvature is likewise the same.

The doctor's method of chemical analysis as given by him cannot be too strongly emphasized, for unless the utmost care is taken in the chemical analysis of the stomach the examination is almost nugatory. It is useless to diagnose upon a single examination of the stomach, because, as he states and as I can testify, a single examination of the stomach may show an absolute absence of hydrochloric acid, while the next one may show the presence of hydrochloric acid in its normal proportion, or even in excess.

I am a thorough believer in the necessity of a thorough examination of the stomach in all cases, because I believe it to be the avenue through which many mischievous germs may be introduced, and by means of which we may perhaps determine what bearing it has upon the introduction of disease to remote parts of the body. Heretofore the stomach has been passed over in a cursory manner. I remember in my student days it was not considered necessary to introduce the stomach-tube, and I have repeatedly, even at a late day, seen a gentleman who stands deservedly high in the profession,-a gentleman who is now an emeritus professor, and has one clinic a week, and who was then professor of internal medicine,-who would introduce several quarts of water into the stomach, and induce the patient to vomit it out, and simply ventured an opinion of the actual condition by the sample of the contents thus obtained. I do not believe he would have done it in his private practice, but in his clinical work he was overburdened and anxious to lay it down.

I was very much interested in Dr. Rees' paper, and interested in the way he handled it.

Dr. Geo. D. Head: There are several points touched upon in the paper which will permit of further discussion. The chief objection that can be raised to this method of determining the amount of hydrochloric acid in the stomach-contents, is that it is not reliable. Lactic acid, if present in the stomach-contents in even small quantities, will give a color-reaction with the dimethyl-amido-benzol solution similar to that of hydrochloric

acid. One could therefore not be certain that the intensity of the color-reaction is due entirely to hydrochloric acid alone, since lactic acid and hydrochloric acid may exist together in the same stomach-contents.

Practically in stomach work one wishes to know the presence or absence rather than the quantity of hydrochloric acid. By determining, first, the total acidity, and, second, the presence of hydrochloric acid by the Gunzberg test, we have secured the essential facts necessary to know in the diagnosis of stomach diseases.

I do not see how anyone can decry the value of chemical methods, and certainly I would protest against the remarks made at this and other meetings regarding the value of the chemical examination of the stomach-contents. Over eighty per cent of Osler's cases of cancer of the stomach show a total absence of hydrochloric acid. If for no other reason than this the chemical examination would be of value, because everyone knows. that in the early stages of cancer of the stomach the diagnosis. is difficult to make, and no stone should be left unturned to establish it.

We must make a diagnosis of this disease of the stomach early, so that the surgeon may have a chance to operate in the early stage. The only way to make an early diagnosis is to take into account the findings of the chemically examined contents. Eighty per cent of cases of cancer of the stomach have shown an absence of hydrochloric acid, and it is very certain that cancer of the stomach causes an alteration of the fluids, which gives us valuable knowledge in diagnosis. There are certain cases of neurasthenia which show an absence of hydrochloric acid. I remember a case of a man who was a marked neurasthenic, and at repeated examinations of the stomach-contents no hydrochloric acid was present, and the diagnosis of cancer was made. The history since then proved that the diagnosis of cancer of the stomach was not correct. In cases of ulcer of the stomach hyperacidity is the rule; however, an ulcer does not always show a marked hyperacidity.

While, therefore, there are no hard and fast rules to guide us in the diagnosis of diseases of the stomach from a study of the gastric findings, the analyses are of great value when studied in conjunction with the clinical histories of these cases.

Dr. L. A. Nippert: I wish to emphasize the posture of the patient during stomach examination. The recumbent position, with the stomach distended, is usually the best for diagnosis, but tumors of the upper part of that organ may escape discovery unless the patient is examined in a standing posture. By this means I have been able to make a diagnosis of carcinoma of the lesser curvature of the stomach, verified afterwards on the operating-table, in a patient who had been frequently examined, with negative results, in the recumbent position. Posture, therefore, is an important means in the diagnosis of the nature of obscure stomach troubles.

Dr. Soren P. Rees (Essayist): I wish to thank the gentlemen for contributing to the paper so materially by their discussion. One object in writing a paper on so general a subject

was to bring out discussion on various points that could not be mentioned in the paper; another object was the fact that on one hand we find bulky text-books full of complex methods that nearly stagger us if we try to follow them, while, on the other hand, we meet with physicians who ignore all laboratory methods, and do not try to make any diagnosis before commencing treatment. Between these two extremes the object was to call attention to some simple, short methods that might be used to good advantage when the others could not be employed.

In regard to dilatation of the stomach: the greater curvature is often found below the umbilicus without giving rise to any pathologic symptoms. A personal friend has investigated five cases in Pomerania where the diet is mostly sour milk, potatoes and salt herring, and in the five cases examined the stomach reached half way to the pubis, yet these people had perfect health. The test-breakfast disappeared in about one hour, and they had five or six passages a day from the bowels.

In regard to the difficulty of mapping out the stomach: I must say that by means of tartaric acid and soda, administered carefully in the way suggested, I do not remember any case during the year where one had any difficulty in mapping out the stomach. The method emphasized by Dr. Quinby is a very valuable aid. The examination of the urine is also important beyond determining any renal lesion, as the acidity of the urine varies with the acidity of the stomach-contents.

I would not, by mentioning this quick and simple test for determining the amount of hydrochloric acid, discourage the use of older tests. What we claim for this color-scale is that by means of it we have a very simple, short, and easily-made test. The stock solutions that we used in making up this little rack were prepared last year, and this morning, in order to have the colors fresh, it did not take us more than probably five or six minutes to add to each test-tube the required amount of reagent, and to complete the rack. It will hold good for a long time.

DILATATION OF THE STOMACH

CHRISTOPHER GRAHAM, B. S., M. D.

Rochester

From January 1, 1901, to January 1, 1902, there were 252 stomach-tests made at St. Mary's Hospital. Of this number 142 were male, 110 females; 85 had dilatation alone; in 25 prolapse was the marked condition, while in 25, prolapse and dilatation both were well in evidence. About 30 were diagnosed clinically as cancer, the diagnosis being corroborated in 18 by later operation. Gastro-enterostomy was performed twenty-eight times: